Parkinson’s Disease
Erica Partridge

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Definition
Aetiology
PD vs Parkinsonism
Symptoms and signs
Differentials
Investigations
Management
Prognosis

1. What is the definition of Parkinson’s disease?

1. What is the definition of Parkinson’s disease?
 A movement disease characterised by
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Tremor at rest
Rigidity
Bradykinesia

2. Aetiology of PD

2. Aetiology of PD
 Degeneration of dopaminergic pathways in the substantia nigra

4. What is the difference between PD and Parkinsonism?

4. What is the difference between PD and Parkinsonism?
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PD is used to describe idiopathic syndrome of Parkinsonism
Parkinsonism is symptoms attributable to an underlying cause

5. Causes of Parkinsonism

5. Causes of Parkinsonism
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Drug induced
 Any drug that blocks dopamine receptors or reduce storage of dopamine
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Mainly antipsychotics
But also antiemetics such as metoclopramide
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Antihistamines – eg cyclizine
5HT3 receptor blockers – eg ondansetron
Dopamine blockers eg metoclopramide, domperidone
Following encephalitis
Exposure to toxins – manganese dust, sever CO poisioning

6. 3 main features of PD

6. 3 main features of PD
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Tremor
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4-6 hz
Seen at rest – can be induced by concentration
Usually apparent in one limb or one side first
Rigiditiy
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Increase in resistance to passive movement
Can produce a characteristic flexed posture
Cogwheel rigidity
Bradykinesia
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Slowness of voluntary movement
Reduced arm swing
Progressive reduction in amplitude of repetitive movements

7. How does PD present

7. How does PD present
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Insidious onset
Peak age of onset is 55-65, slightly more common in men
Impairment of dexterity
Progressive disorder

8. Other symptoms

8. Other symptoms
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Fixed facial expression
Infrequent blinking
Quiet voice
Micrographia
Gait – short shuffling steps (festination), difficulty in initiating movement and in stopping
Non motor
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Anosmia
Depression
Dementia
Visual hallucinations
REM sleep disorders

9. Differential diagnosis

9. Differential diagnosis
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Benign essential tremor
 Far more common – worse on movement, rare at rest
Drug or toxin induced

10. In which type of dementia do patient’s have PD symptoms?

10. In which type of dementia do patient’s have PD symptoms?
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Lewy body dementia
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Dementia
Fluctuating levels of awareness
Signs of mild PD
Visual hallucinations
Sleep disorgers
PD dementia
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Dementia occuring >1 year after PD diagnosis
Visual hallucinations
Fluctuating lucidity

11. Diagnosis of PD

11. Diagnosis of PD
 Bradykinesia plus one of following
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Muscular rigidity
Resting tremor
Postural instability
 Not causes by primary visual, vestibular, cerebellar or proprioceptive dysfunction

12. Investigations

12. Investigations
 Diagnosis is clinical

13. Management

13. Management
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Levodopa
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Taken with a decarboxylase inhibitor
Start with low dose and build up
Keep dose as low as possible
N+V/loss of appetite
Dopamine agonists
 Eg bromocriptine, cabergoline
 Monotherapy or adjuvant
COMT inhibitors
 Must be taken with levodopa
 Eg entacapone, tolcapone

 MAOBi
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Prevent dopamine being broken down
Selegine
 Has amphetamine metabolites – hallucinations, nightmares, confusion so avoid in elderly
Rasagiline
 No amphetamine metabolites

COMT
Breakdown product
Levodopa
AADC
(decarboxylase)
MAO
Dopamine
COMT
Breakdown product
Breakdown product
BBB

14. Other management

14. Management
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OT
SALT
 Exercises to strengthen voice/help control facial expression/swallowing or drooling problems
 Suggest communication aids
Physio
PD nurse
Support groups

15. Common management problems

15. Common management problems
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Motor fluctuations – associated with long term L-dopa
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On off fluctuations – occur randomly
Wearing off phenomenon – before next dose is due
Involuntary movements while on – dyskinesias
Axial problems
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Do not respond to treatment
Balance, speech and gait
Physio, SALT, OT
Associated disease
 Dementia (20-40%)
 Depression (45%)

16. Complications

16. Complications
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Infections
Aspiration pneumonia
Bed sores
Poor nutrition
Falls
Contractures
Bowel and bladder disorders

17. Prognosis

17. Prognosis
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Slowly progressive with mean duration of 15 years
Severity is hugely varied
Some show little disability after 20 years
Others severely disabled after 10 years

Explaining things to patients

Explaining things to patients
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What do they already know
Why they need it
What will happen
Risks/side effects
Do they have any questions?
 It is fine if you don’t know the answers say you will find out and get back to them
Offer to give them information sheets/leaflets

References
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Patient UK Professional Reference
NICE guidelines
Parkinson’s UK website